Elsevier

Gynecologic Oncology

Volume 100, Issue 3, March 2006, Pages 455-461
Gynecologic Oncology

Diagnostic open laparoscopy in the management of advanced ovarian cancer

https://doi.org/10.1016/j.ygyno.2005.09.060Get rights and content

Abstract

Objective.

Optimal primary cytoreductive surgery (OPCS) plus adjuvant chemotherapy (AC) represents the standard management for patients with advanced ovarian cancer (AOC). Recently, some authors have suggested the use of neoadjuvant chemotherapy (NACT) followed by interval debulking surgery (IDS) in patients with unresectable AOC. This study has been started to evaluate the role of diagnostic open laparoscopy (DOL) in predicting who are the best candidates to OPCS.

Methods.

All patients newly diagnosed as affected by AOC were submitted to DOL in order to establish the possibility of OPCS considered as no residual tumor left after operation. Patients considered not susceptible of OPCS were submitted to three cycles of NACT, administered every 3 weeks (Carboplatin, targeted AUC = 6, plus paclitaxel 175 mg/mq), followed by IDS and adjuvant chemotherapy.

Results.

From January 2000 to March 2004, 87 patients with AOC underwent DOL. Fifty-three patients (61%) were judged operable and therefore submitted to primary cytoreductive surgery (Group A). Optimal debulking rate in this group of patients was 96%. Thirty-four patients were judged affected by disease not cytoriducible to absent residual tumor and therefore scheduled for NACT-IDS-AC (Group B). Twenty-five patients were judged with partial clinical response and were therefore scheduled for IDS and AC. Optimal debulking rate (no residual tumor ) in Group B patients was 80%.

No major perioperative complications, due to laparoscopy, occurred. All Group B patients received the first cycle of chemotherapy the day after DOL.

In 34 patients (39%), an explorative laparotomy was avoided. With a median follow-up of 22 months (range 2–49 months), the proportions surviving were 87% and 60% in Group A and Group B patients, respectively.

Conclusion.

DOL could be considered a valid diagnostic tool in evaluating the extent of disease in AOC. Our data suggest that the use of DOL leads to decrease the rate of primary cytoreductive surgery for AOC; on the other hand, a higher optimal debulking rate (no residual tumor) at primary surgery is achieved.

Introduction

Optimal cytoreductive surgery followed by platinum-based chemotherapy is the standard therapeutic strategy for patients affected by advanced ovarian cancer. It is well known that residual tumor after surgery has a strong prognostic impact on these patients [1], [2], [3], [4]. The definition of optimal cytoreduction has varied from 0 to 3 cm maximum diameter of residual tumor left in place. However, thanks to improvements in surgical technique and standing the firm conviction that residual tumor after surgery is one of the most powerful and independent factor affecting prognosis, all the authors agreed that the status “no gross macroscopic disease” should be the goal to pursue in order to obtain the best overall survival. The success rate of achieving optimal cytoreductive surgery varies among reporting institutions and, generally, the percentage of macroscopically tumor free patients does not exceed 50% even in experienced surgical centers [4], [5]; a remarkably high percentage (85%) of advanced ovarian carcinoma patients who are free of residual tumor has been reported by Eisenkop et al. [6]; however, this rate could not be reproduced by other cooperative study groups.

It is important to remember that ultraradical surgical techniques led to considerably increased perioperative morbidity and mortality [7], [8], [9]. In addition, chemoresistance to conventional adjuvant chemotherapy could render these surgical maximal efforts not helpful in improving prognosis.

In the last decades, many authors have proposed the use of neoadjuvant chemotherapy followed by interval debulking surgery in advanced ovarian cancer patients, reporting enthusiastic results in terms of optimal debulking rate, intra- and postoperative complications and survival [10], [11], [12], [13], [14], [15], [16], [17], [18], [19], [20], [21].

The rationale of such a strategy in the context of the primary treatment of advanced ovarian cancer lies in a higher cytoreducibility to the optimal status, possibly intended as absent residual tumor left, facilitated by chemotherapy.

An EORTC randomized trial is currently ongoing comparing neoadjuvant chemotherapy followed by debulking surgery vs. primary debulking surgery plus adjuvant platinum-based chemotherapy (#55971).

However, until these data will be evaluated, we can assume that patients who benefit the most from neoadjuvant chemotherapy are those in whom cytoreductive surgery cannot be performed optimally at first surgery.

Laparotomy constitutes the most accurate way to evaluate tumor burden and establish whether or not a patient is suitable of optimal surgery. However, it is an aggressive approach if used only to assess tumor resectability. Some investigators have suggested the use of preoperative CT scan in prediction of optimal debulking [22], [23], [24], [25]. Other authors have found an association between preoperative CA 125 levels or ascites and success in achieving an optimal debulking rate [26], [27], [28], [29]. Berchuck et al. used molecular microarrays to identify patients suitable of optimal debulking [30]. Recently, some investigators have focused their attention on laparoscopic procedures in order to assess resectability in advanced ovarian cancer patients [13], [31]. Advantages of laparoscopy include magnification of pelvic and abdominal anatomy, enhanced visualization of metastases of the upper abdomen, surface of the liver and diaphragm, posterior and anterior cul de sac. In addition, the short operative time and the avoidance of opening the abdomen permit a quick postoperative recovery, reduce operative morbidity and avoid delay in starting chemotherapy.

The aim of this study is to report our data on diagnostic open laparoscopy used to assess the possibility of achieving an optimal cytoreduction intended as “absent residual tumor left status” after debulking in advanced ovarian cancer patients. In addition, we would expose our surgical and survival data on interval debulking surgery and primary cytoreduction.

Section snippets

Patients

Patients affected by strongly suspicious advanced ovarian cancer (FIGO stage IIIC–IV) were enrolled in the study. Inclusion criteria were: performance status <2 according to WHO criteria, good nutritional status, no contraindications to surgery, signed informed consent. Preoperative evaluation included: general and gynecological examination, pelvic ultrasonography, serum CA 125 level, blood tests, EKG, chest X-ray and computed abdomino-pelvic tomography (CT) scan. All patients were submitted to

Results

From January 2000 to March 2004, 87 patients with diagnosis of advanced ovarian cancer underwent diagnostic open laparoscopy. Characteristics of the patients are showed in Table 1. After diagnostic open laparoscopy, 53 patients (61%) underwent primary cytoreductive surgery (Group A) and 34 patients (39%) were closed and submitted to neoadjuvant chemotherapy (Group B). Surgical procedures associated to total abdominal hysterectomy plus bilateral salpingo-oophorectomy and omentectomy attempted in

Discussion

Standard treatment of advanced ovarian cancer consists of complete surgical tumor resection (to the greatest extent possible) followed by platinum-based chemotherapy.

The rationale of the benefits obtained with a maximal surgical effort is pertinent to the increased sensitivity of tumor cells to chemotherapy in the presence of small tumor foci. However, considering the re-growth of tumor cells occurring between cycles of chemotherapy, the theoretical benefit of cytoreductive surgery should be

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